Category Archives: Life and Death in the ER

“Oh God!” she groaned, looking upward with tears flooding her cheeks, which were stretched into the shape of agony. Her chest heaved uncontrollably with grief.

“I am so very sorry,” I whispered again while leaning in and stroking her hand.

This is what death notification often looks like and feels like. We doctors should be masters of delivering some of the worst news that could ever be uttered, the worst news that could ever be heard. Continue reading →

A “Sign” is defined as an object, quality or event whose presence indicates the probable presence of something else.

One day after having read, “Attending the Dying” by my friend Megory Anderson, I found myself at work in the ER. There was a half-naked psychotic lady screaming in the hall, the sound of a beeping ventilator alarm escaped from the curtained room of a man in respiratory failure, and a large crowd was gathering outside of Bed 2 because a matriarch was dying. Although I am accustomed to such visual and auditory chaos, it struck me that my dying patient and her family were not. Further, as I stood in this hall with the family whom I was attempting to shepherd along in creating a good death for their well-loved matriarch, I became acutely aware that I was not following the wise counsel set out by my friend, Megory.

In her brief and powerful tome, “Attending the Dying- A Handbook of Practical Guidelines”- Megory sagely advises those of us who accompany others on their journey towards last breaths. Standing in the bustle and roar of the ER, I could clearly recall her words regarding creating a sacred space for the dying and their loved ones:

“You have the calling and ability to set the stage for a good and holy death.”

“Creating sacred space is one of the first steps in setting the environment apart from day-to-day issues, which in turn helps everyone present remember the sacredness of the event unfolding.”

“Contain or mark the space.”

“Try to make this an intimate experience for the family, within the boundaries of the medical unit.”

“A sign on the door is always appropriate.”

Hmm…I thought, “What I really need is a sign. But what would it say?”

I mused that my favorite sign would go something like this:

“Shut up! Can’t you see that someone is dying in here?”

Being known for my public decorum, however, I decided against this one. But, what?

I could not imagine the family wanting a sign on the door that overtly stated that someone was dying. This would rob them of some of the privacy that I was hoping to create.

I could not come up with anything decent and reasonable on my own so I turned to the experts. In my ER, we have these fabulous humans called “Patient/Family Representatives” whose job is to socially, emotionally and spiritually help support and gain resources for people who are critically ill or dying. If ever there was a font of wisdom, these people are it! So, I presented the idea to them and of course they had the solution and here it is:

Ah, now there we go.

This sign promotes respect and privacy without announcing the condition of the patient.

So the point is that indeed a sign is often a necessary, simple and powerful tool in defining a sacred space for the dying, particularly in a medical facility. But remember, when creating YOUR OWN signs for this purpose: A “Sign” is defined as an object, quality or event whose presence indicates the probable presence of something else. You have to understand the sign to obey it!

Make sure your sign is recognizable, respectful, and gets the job done.

Thank you, Megory, for teaching us how to better attend the dying and to groom the environment practically and with dignity, even within the chaos of the ER.

Dr. Megory Anderson was called to a vigil at the bedside of a friend who was dying one night. That experience was so powerful that she began working with others who needed help attending to those who were dying. Today, Anderson is the executive director of the Sacred Dying Foundation in San Francisco, and trains others in the art of “vigiling,” a way of attending to the needs of the dying. She may be reached at: Megory@sacreddying.org

I was at the end of a long shift. I had already seen too many patients to have any common sense left and it felt as though there were no remaining neurons firing in any agreeable pattern in my brain. And here came my last patient. I peeked into her room before I showed my own face. She was 78 years old with long gray curls piled way atop her head. Her chest seemingly rose and fell too rapidly for comfort. The sounds of bubbles in her airway were audible even outside of the room.

“Uh oh,” I thought…fate has saved the toughest patient for last. Tough because at first glance I could already tell that I would need to have an end-of-life planning conversation with this little lady. She was already triggering my mental screening tool: Would I be surprised if this patient died within the next year?
The answer was a resounding “no.”

I pulled back the curtain.

“Hi Toots!” She called out to greet me as I made my way into her room. (This was a first…and I liked it!)

This spunky little lady was in the ER for shortness of breath. Again.

As we talked it became clear that she had entered her end-of-life pathway. The last six months she had multiple hospitalizations for pneumonia. She now only routinely walked to the restroom or to the dinner table. She was beginning sleep a lot and there was about 20 lbs. weight-loss.

Despite my fatigue it was my duty to have “the conversation” with this patient and her husband, regardless of the physical and mental energy costs to myself.

So I took a deep, tired, ragged breath and started my usual condensed ED-goals of care conversation:

“Do you have a living will?”

Her husband quickly responded, “What’s a living will?”

Secretly, in the recesses of my imagination, I slapped my forehead, yelled out “Oh brother!” and rolled my eyes. As I sat motionless, fake-smiling at the gentleman, I hoped that none of my true sentiments had shone through in my facial expressions or demeanor.

Before I could continue my spiel with this fake-smiling expression plastered on my face the husband asked, “Does that mean that we ask about her wishes?”

Oh wow!

Suddenly I felt as refreshed as after a good nights sleep! “Why yes!” I gushed to
him, my fake-smile now genuine and deep.

“Well, let’s just ask her then,” he said turning to her as my smile turned to an expression of near-astonishment. This had never happened before.

“Honey,” he leaned over her bed rail, “This nice doctor wants to know your wishes like whether or not you want life support and things like that.” He looked toward me as he spoke to her searching my face for confirmation.

Boy, did he get it! I was shaking my head vigorously, “YES!”

Her response?

“Well, I don’t want all of that. You see, I only want to die once.” She said impishly.

We all burst into laughter.

She apparently took this as her cue. So, she continued, “I mean who in their right mind would want to die twice? Right?”

(She began to remind me of Joan Rivers on stage.)

She kept going…”Why break my ribs just so I can come back to do it all over again? And who came up with that plan anyway, doctor ?!?”

#LOL #ROFL were understatements!

Observing my uncontrolled laughter she said, “At least you’ve got a sense of humor kid. But let’s get on with this admission, I’m hungry….”

So, we did.

—–

Lesson 1- Things are not always as they first appear. Sometimes we are pleasantly surprised.

Lesson 2- Fatigue is no excuse for skipping what could be the most important healthcare planning conversation in a patient’s whole life.

Lesson 3- Always find a reason to smile or laugh with your patients (even if it’s a choice )

“If you don’t want to deal with death and dying, then you need to quit medicine now and become an accountant…because this is what we have signed up for and we’ve got to do a better job at it.” Continue reading →

I love hospitalists, they are some of my favorite people. Like me, they come into the hospital and work their butts off for 10-12 hours with very little food or water. We are essentially kinfolk, and we take care of the same patients.

Because we are comrades, I make sure to meet and greet with hospitalists each time I see them. (Some of us even hug!)

One of my favorite hospitalist was in the ER today when I arrived, and somehow (of course) we got on the subject of advanced directives. He told me that his own living will says that when he cannot wipe his own ass, then doesn’t want to be kept alive by any medical interventions. (Excuse his “French”)

We both laughed knowingly.

He said that when he shared his living will with his wife, she freaked out. In her distress, she asked, “Don’t you love me? Don’t you love the children?”

He said, “Of course I do, however my definition of life meaning means being able to actually live.”

Pensively, I remarked, “We’ve seen too much haven’t we?”

We both nodded in agreement. Then, we both smiled and he admitted my next patient-an hundred-year-old man who could no longer wipe his own ass.

Recent articles suggest that doctors typically do not want aggressive measures for themselves at the end of their own lives.

Most of the time I feel as though I am “running in quicksand” attempting to bring patients to a place of grace and dignity in dying. On occasion, there is someone who jerks me out of my quicksand and plants me squarely on stable shore and then proceeds to show me what grace and dignity in the face of death really look and feel like.

I live and work in the house medicine. You would think that those of us who have chosen this profession would actually know what dying looks like. Furthermore, one would hope that if the doctor could identify dying, he or she could share this with the patient and family (given that this is fairly significant medical information!). Continue reading →

Ok, well I am neither a good actor, nor producer but don’t let that stand in your way of receiving my message…Hospice care can be activated ANYWHERE within the healthcare system (and even outside of it) when the patient is ready!

The ER (besides the ICU and Surgery Suite) may be one of the most aggressive, intervention-focused areas in the house of medicine. So, if WE can do it, then ANYONE can do it (meaning, transition patients to hospice care when appropriate.)

Here are some tips from my Emergency Department:

1- Signage

ER docs like to look at algorithms. It’s the way we are trained, just open up any ACLS guideline and you will see what I mean. So, in our emergency department we have a sign at each doctor workstation which reads:

“Signs that a person may be ready for hospice care”

Weight Loss

Increased pain, nausea, fatigue or other symptoms

Increased need for assistance

Decreased alertness

Increased hospitalizations

Family exhausted from care-giving demands

(At the bottom of the sign are directions on how to make a referral).

2. Train your staff to screen for hospice readiness

My nurses ask all kinds of questions to patients during their initial screening:

“Do you have any religious, or cultural preferences that might affect your care today?

“Do you feel safe at home?”

“Would you accept blood products to save your life?”

So, you see, we are accustomed to asking deeply probing questions from the get-go, so why not also ask end-of-life screening questions:

“How many times have you been to the ER or hospitalized in the last 6 months?”

“Do you feel like your health is steadily failing with worsening symptoms?”

“Are you feeling tired from the amount of care-giving required for your loved one?”

Identifying the potential hospice-appropriate population goes along way toward getting them the care they need in a more timely manner.

3. Build relationships with local hospice providers

Our hospital has an affiliate relationship with a local not-for-profit hospice who serves as our preferred provider. RNs from this hospice have affiliate hospital privileges at our institution. So, if we call… they come. This takes a huge burden off of the ER staff in transitioning care– our role just becomes one of “screener”- we “screen” the patient and family for physical and emotional “hospice readiness” and then can simply call for a consultation.

OR, if we have a patient who desires another hospice who doesn’t have affiliate privileges, OR if we have a clear-cut, “I want to go home on hospice” patient, then we can simply call the hospice service of choice (make sure their numbers are readily available to the secretary) and have the hospice RN meet them at their home or home facility for intake.

NOT COMPLICATED!

So, the bottom line here is, if we can do it, anyone can do it.

How does your department or institution make hospice referrals easier? Please share!

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